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61 Cards in this Set

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Nurses role in the preoperative phase
-Patient and family education
-Thorough assessment
-Prepares pt. for OR
-Administration of medications
-Documentation
Preadmission phase
-Begins at MD office
*Medical Hx within 30 days
-Preadmission testing
*Labs within 7 days (if >60yoa)
*EKG withing 90 days (if >45yoa)
-Nursing Hx (in person or over phone)
-Pre-op teaching
-Special instructions
-Special Consents
-Anesthesia Evaluation
Pre-Op Phase
-Nursing Assessment
-Physical preparation
-Complete pre-op checklist
-emotional/psychological concerns
-Reinforce &/or initiate pt teaching
-Document everything!
Patient's psychological response to surgery
Pre-operative fear/anxiety r/t unknown outcome of surgery, possible death, pain, loss of work time, perceived burden on family, permanent incapacity
Patient's physiological response to surgery
Fill in later
Spiritual and Cultural Beliefs and Surgery
-Play role in how pt copes with fear and anxiety
-Pt's beliefs should be respected and supported
-Spiritual help should be obtained if requested by pt
Nutritional Status and surgery
-Helps promote healing and resisting infection
-The body has an increased need for:
*protein: tissue repair
*calories:
*water: replace lost fluid, maintain homeostasis
*Vit C: capillary fx, wound healing
*Vit A: immune system, tissue repair
*Vit K: normal blood clotting
*iron: replace iron lost through blood
*zinc: protein synthesis & wound healng
NPO status before surgery
-To prevent aspiration during surgery
Lab Values:
RBC: 5-10
WBC: 5 - 10 (infection)
Hgb: m: 13.5-18 f: 12-16 (anemia, GI bleed)
HcH: m: 40-54% f: 38-47%
U.A.: 2.5-6.0 (dehydration)
BUN: 6-20 (Dehydration, GI bleed)
Creatine: m: .6-1.3 f: .5-1.0 (dehydration)
Nurse's fx after admin of sedative pre-op
-Before giving the nurse should allow pt to void
-Assess vital signs
-Pt safety: side rails up...
-Room should be quiet to allow for relaxation
Major areas to check on preoperative checklist
-Patient allergies
-Consent forms w/ signatures
-Lab report/EKG report
-Med sheets
-Pt admission assessment
Why all routine and PRN meds are stopped when pt goes to surgery
-Because of the possible effects of medication on the pt's peri-op and perianesthesia and possible drug interactions
Benefits to pre-op teaching
-Reduced fear and anxiety
-Empowers pt to become active participant
-Decreased post-op vomiting, pain, and need for analgesia
-Shorten hospital and recovery time
-Enhances coping mechanisms
-Increases surgical experience
Principles of teaching that should be utilized
-Motivation
-Readiness to learn
-Active involvement
-Feedback (reinforces learning)
-Organizing logically
-Relating to prior experience
-Match pt's learning style
-Short learning and application time
-Assess environmental factors
Information that should be included during pre-op teaching
-Time of surgery
-Food and fluid restrictions
-Informed consent
-Physical preparation (enemas, IVs...)
-Intraoperative expectations
Three Domains of learning (B. Bloom)
-Cognitive domain: involves knowledge & the development of intellectual skills. This includes the recall or recognition of specific facts
-Affective domain: includes the manner in which we deal with things emotionally, such as feelings, values, appreciation, enthusiasms, motivation, & attitudes.
-Psychomotor domain: includes physical movement, coordination, & use of the motor-skill areas.
4 physical changes that effect learning in the older adult pt
-Sensory: vision, hearing, touch, and smell
-Motor control: decreased muscle strength, loss of flexibility, & endurance
-Nervous System: reduced speed of nerve control, conduction, confusion, slow response and reaction time
-Memory Loss: slow recall or poor short-term memory
-Nursing Interventions:
-Set achievable goals
-Use visual aids in large print
-Increase teaching time
-Allow for rest periods
-Repeat information
-Use prior experience, examples the pt can relate to
-Teach in a quiet environment, comfortable to the pt
Complications of positioning
-Undue pressure on a body part should not obstruct vascular supply (postural hypertension, venous pooling, compartment syndrome)
-Respiratoin should not be impeded by pressure of arms on chest (dyspnea)
-Nerves must be protected from undue pressure, improper positioning can cause serious injury or paralysis (injury of brachial, ulnar, radial, sciatic, tibial, or peroneal nerves)
-Integumentary breakdown of the skin and scalp (alopecia)
-Reproductive (genital injury)
-Sensory effects (corneal abrasion, conjunctival edema, ear injury)
-Skeletal (aseptic necorsis of femoral head, fx of symphysis pubis)
-Muscular pain in lumbar, neck, and shoulders
-Precautions for pt safety for thin/elderly, obese and pts with deformities or handicaps
Surgical Asepsis
Absence of microorganisms in the surgical environment to reduce th risk for infection
Intra-operative heat loss and hypothermia
During anesthesia, pt's temp may drop:
-Reduced glucose metabolism may cause metabolic acidosis
-Core temp: < 98.0
Caused by:
*low OR temp
*infusion of cold fluids
*inhalation of cold gases
*open wounds or body cavaties
*decreased muscle activity
*advanced age
*pharmaceutical agents
Signs and symptoms of malignant hypothermia
-Inherited muscle disorder chemically induced by anesthetic agents
-Tachycardia
-Ventricular dysrhythmia
-Hypotension
-Decreased cardiac output
-Oliguria (decreased urine volume)
-Abnormal transport of calcium causes:
*tetanus like movements (often in jaw)
*rigidity
-Late sign: rapid increase in temperature
Precautions taken by OR team to prevent medical-legal problems
-Check patient's ID band
-Have state and spell full name and date-of-birth
-Ask pt to list any allergies
-Mark the site on the patient
-All instruments to be used during the surgery are counted and documented on the white board before the surgery and again at the end of the surgery
Regional Anesthesia
-The temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body
-Epidural
-Spinal
-Caudal
-Nerve block
Epidural
-An injectin into the the epidural space inside the spinal column (not in the dura mater)
-Will have a higher dosage than spinal because doesn't make direct contact with spinal cord or nerve roots
Spinal
-aka subarachnoid block
-lumbar puncture between L4 or L5 or S1
-Injected into subarachnoid space
Caudal
-aka transsacral
-produces anesthesia of the perineum and occasionally the lower abdomen
Nerve Block
-A technique in which the anesthetic agent is injected into and around a nerve or small group of nerves
Advantages of using spinal or epidural rather than general anesthesia
-Patient awake with spinal/epidural
-Minimal effect on respiratory and CV systems
-Decreased recovery time
-Prolonged analgesic effect post-op
Reasons for using epinephrine with local anesthetics
-It contricts blood vessels, which prevents rapid absorption of anesthetic
-Prolongs local action
-Prevents seizures
Conscious Sedation
Will fill in later
Post-op Urine output
-Anesthetics, anticholinergic agents and opiods interfere with perception of bladder fullness and inhibit the ability to void within the 8 hours of surgery
Progressive Diet
will fill in later
Corticosteroids
-Ex: prednisone
-Interaction: Cardiovascular collapse can occur if d/c'd suddenly
-A bolus may be given before and right after surgery
Diuretics
-Ex: hydroDIURIL
-Interaction: may cause respiratory depression resulting from an electrolyte imbalance
Phenothiazines
-Ex: Thorazine
-Interaction: may increase hypotension action of anesthetics
Tranquilizers
-Ex: Diazepam (valium)
-Interaction: may cause anxiety, tension, and seizures if withdrawn suddenly
Antibiotics
-Ex: erythromycin
-Interaction: When combined with a curariform muscle relaxant, nerve transmission is interupted and apnea from respiratory paralysis may result
Antisezuire
-Ex: phenttoin (dilantin)
-Interaction: may need to be administered IV to keep pt from having seizure during surgery
Monoamine Oxidase (MAO) inhibitor
May increase the hypotensive action of anesthetics
Informed Consent
Voluntary and written:
-must be freely given, without coercion
-Should contain explanation of surgery, description of benefits and alternatives, an offer to answer questoins , Instructions that inform pt that they may withdraw consent, a statement informing pt if the protocol differs from customary procedure
-Important: protects the pt from unsanctioned surgery and protects the surgeon from claims of of an unauthorized operation
Suffixes used
-ectomy: removal of
-lysis: destruction of
-orrhaphy: repair or suture of
-oscopy: looking into
-ostomy: creation of opening into
-plasty: repair or reconstruction
Wound healing: Primary
-Wound is clean in a straight line, with little loss of tissue
-All wound edges are well approximated with sutures
-Usually rapid healing with minimal scarring
Wound Healing: secondary
-Large wound with considerable tissue loss
-Natural healing by formation of granulation tissue
-Healing takes longer and results in more scarring
Wound Healing: Tertiary
-Time delay before wound is sutured
-Greater granulation, risk of infection, inflammatory reaction than primary intention
-Late suturing and more scaring
Factors affcting Wound Healing
-Good handwashing
-Diet: vit C and protein
-Adequate hydration
-medications
-Splint incision when CDB
-Type and location
-Pt age
-Other medical Dx
-Lifestyle factors
Phases of wound healing
-Inflammation:
*1-7 days
*WBC, clot formation, cell migration
-Proliferation:
*7-30 days
*new tissue, granulation, diet important
-Maturation
*21 days to several months (even years)
*tissue strengthens, scar is reduced
Terms R/T Wound Healing
-Granulation: migration of fibroblasts with secretion of collagen and new capillary formation (wound is fragile and bleeds easily)
-Eschar: thick necrotic tissue (may be white, black, or gray)
-Debridement: removal of non-viable tissue (may be done surgically or mechanically)
Problems Interfering with Wound Healing
-Dehiscence: partial or complete seperation of wound edges
-Evisceration: dehiscence with abdominal contents protruding from wound
-Infection: characterized by increased temp of surronding tissues, swelling, redness, purulent drainage; Dx with wound culture, increased WBC
Deep Vein Thrombosis
-Risk factors: dehydration, decreased cardiac output, venous pooling, bedrest, and hypercoagulability, history of oral contraceptives
-S/S: + homan's test, edema, increased temp & HR, chills, redness, cramps
-Prevention: leg exercises, AE or pneumatic hose, early ambulation, adequate hydration
Pulmonary Embolism
-DVT breaks loose and moves to pulmonary artery
-May be mild or severe
-Mild = vague S/S
*Dyspnea, mild substernal pain, cough-hemoptysis, increased resp rate & HR
-Sever = acute S/S
*Sudden, sharp, stabbing substernal pain
*pulse is rapid, weak, thready, cyanosis
Nursing Management of DVT & PE
-Pt placed on bedrest
-Ensure adaquate hydration
-Anticoagulant therapy initiated
-With DVT, goal is to prevent PE
-Administer oxygen
-With PE goal is to ensure adequate oxygenation & prevent resp distress &/or resp arrest
**Early ambulation key to prevention
Common Pre-operative Meds
-Histamine Antigonists/Antiulcer
*Zantac/ranitidine
-Anti-emetics
*Reglan, Zofran
-Alkalinizing agent
*Sodium Citrate: prevents aspiration
-Opioids/Analgesics
*Demerol, methadone
-Sedatives/Hypotonics/Anti-anxiety
*Ativan, Halcion, Valium, Xanax
Acute Pain
-Recent onset
-Associated with specific injury
-Defined as lasting from a few seconds to up to 6 months
Chronic Pain
-Constant or intermitten
-Persists over time
-Difficult to treat
-Lasts > 6 hours
-Serves no useful purpose
-Leads to: depression, irritability, disturbed sleep, loss of libido, and appetite
Assessing Pain
-Basic parameters: location, intensity, quality, chronology, other sx
-Tools for assessing: intensity rating scales, physiologic indicators, behavioural responses
-Factors influencing pain response: past experiences, age, depression, anxiety, culture, ethnicity
Pain Management
-Narcotics: work on CNS, side effects: N/V, constipation, sedation, tolerance, resp. depression, urinary retention

-Non narcotics: work on peripheral nervous system, anti-inflammatory
Respiration Management
-hypoventilation leads to atelectasis, pneumonia
-Increased risk: thoracic and upper abdominal surgeries, elderly or obese
-Check resp. rate and lung sounds
-Encourage DB and voldyne use
-Evaluate effect of meds on resp.
-Evaluate need for O2
-Increased temp may indicate increased secretions
-Important 24-36 hours after surgery: deep breathing and couging
Shock
-A condition in which systemic BP is inadequate to deliver O2 to vital organs
-Untreated can result in cell starvation and organ dysfunction
-Can progress to organ failure and death
-Adequate blood flow requires:
*adequate cardiac pump
*effective circulatory system (blood vessels)
*adequate blood volume
*adequate CBC and hemaglobin capacity
Types of Shock
-Hypovolemic: decreased blood volume
-Cardiogenic: decreased pumping ability
-Distributive/vasogenic: blood vessels
-Neurogenic: massive vasodilation r/t loss of sympathetic tone
-Anaphylactic: massive vasodilation and capillary permeability r/t allergic reaction
-Septic: maldistribution of blood volume and decreased myocardial Fx r/t overwhelming infection
*Three causes:
-Heart, Blood, Blood vessels
S/S of shock
-Feeling of anxiety
-Pallor with color, clammy skin
-Nervousness, apprehension, confusion
-Comabtiveness
-Rapid, shallow respirations
-Increased pulse
-BP WNL at first then decreases
-Hypoactive bowel sounds
-Conc. Urine or no urine output
-change in LOC
-Labs: low O2 sat and H&H
Management of Shock
-Early intervention is key
-Give oxygen to counteract hypoxemia
-Trendelenburg position (except in neurogenic)
-Treat cause: stop bleeding, replace fluids
-Administer meds:
-Keep warm
-Frequent VS